2

CE

HOURS

By Kathleen McCullough-Zander, MA, RN, CTN,

and Sharyn Larson, BS, RN, PHN

Continuing Education

Fear

The

Is Still in Me:Caring for Survivors of TortureHow to identify, assess, and treat thosewho have endured this extreme trauma.Editors note: The three cases that begin this article are composite characters basedon real survivors of torture. The fourth case, that of the Cambodian woman, isreal, but details have been changed to protect her anonymity.

hile visiting the home of a 34-year-old immigrant from Cameroon who recentlydelivered her second child, a public health nurse notices that the womans husbandseems overly vigilant. During the visit, the couples three-year-old son makes aloud noise by hitting a plastic toy against a wooden table. The husband jumps upat the sound, then yells at his son for making noise. After her husband leavesthe room, the woman explains that he doesnt sleep well and that he hasnt been thesame since his imprisonment in Cameroon for organizing a public demonstrationcritical of the governments human rights abuses. Weeping, she explains that herhusband used to be a happy person who enjoyed life. She says she doesnt knowwhat was done to him during his imprisonment because he wont discuss it withher, and now she doesnt know how to help him.A 26-year-old Iraqi man comes to the ED of a county hospital complaining ofchest pain. The man speaks limited English. While waiting for the Arabic interpreter, the nurse checks his blood pressure and pulse, which are 150/98 mmHgand 110 beats per minute, respectively. Using gestures, she indicates that the manshould remove his shirt and lie down; he seems nervous but complies. As sheplaces cardiac monitor electrodes on his chest and begins connecting the monitor

Kathleen McCullough-Zander is the former clinic manager, St. Paul Healing Center, and Sharyn Larson is theclinic manager, Minneapolis Healing Center, both facilities of the Center for Victims of Torture in Minneapolis.Some of the research mentioned here was funded by local grants from the Otto Bremer Foundation, the ArchibaldBush Foundation, and the Blue Cross and Blue Shield Minnesota Foundation. Contact author, Sharyn Larson:(612) 436-4814, slarson@cvt.org. The authors of this article have no other significant ties, financial or otherwise,to any company that might have an interest in the publication of this educational activity.

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Image courtesy of the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark

early 1980s. The artist, who wishes to remain anonymous, is a survivor of torture.

cables, she notices dime-size scars on his chest. The

man sits up suddenly and pulls off the electrodes,shouting, No! No! He grabs his shirt and walksout of the ED.A 24-year-old Ethiopian Oromo woman has anappointment at a neighborhood clinic. Uponreviewing the patients chart, the clinic nurse noticesthat the patient has visited the clinic four times inthree months with abdominal and lower-back pain.Twice this woman was hospitalized for testing; allajn@lww.com

results were normal. When the nurse asks how she

feels today, the patient places her hand over herlower abdomen and says, Please, you must helpme. I have terrible pain.Although you may not realize it, if your patientpopulation includes refugees, you are probably caring for survivors of torture. The cases describedabove represent just three of an estimated 400,000to 500,000 survivors of torture now living in theUnited States.1 Amnesty Internationals most recentAJN October 2004

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annual report cites instances of torture and ill treatment by state authorities in 132 out of 155 nations(85%)including the United States.2 A literaturereview conducted by Eisenman and colleagues foundthat between 5% and 35% of refugees (men,women, and children) worldwide have been tortured.3 And in particular cultural groups, the percentage of torture survivors may be even higher. Forexample, a recent study conducted in Minnesotaamong Ethiopian Oromo and Somali refugees foundthe prevalence of torture to be as high as 69%.4Countries that have ratified the United Nations1984 Convention Against Torture and Other Cruel,Inhuman, or Degrading Treatment or Punishment(including the United States, in 1990) are legallybound to ensure that health care personnel learnabout torture.5 But such education has not yet beenincluded in the curricula of U.S. schools of nursing.The Center for Victims of Torture (CVT; www.cvt.org) in Minneapolis, where each of us hasworked or works, focuses on treating survivors oftorture by foreign governments. The CVTsresources are limited and so therefore is its focus;although torture is sometimes perpetrated by U.S.citizens against U.S. citizens, it was thought thatthese survivors would have greater access to themainstream health care system. This article focuseson immigrants or refugees living in the United Stateswho have been tortured.AN OVERVIEWTorture defined. The Geneva Conventions that werewritten in 1949 and ratified by the United States in1955 constitute the main source of internationalhumanitarian laws today, according to HumanRights Watch.6 The conventions explicitly forbadephysical or mental coercion and made the use oftorture a war crime; they were a basis for the 1984United Nations convention mentioned above. In1975 the World Medical Association defined torture as the deliberate, systematic, or wanton infliction of physical or mental suffering by one or morepersons acting alone or on the orders of any authority, to force another person to yield information, tomake a confession, or for any other reason.7 In its1998 position statement on nurses and torture, theInternational Council of Nurses stated that nurseshave the duty to provide the highest possible level ofcare to victims of cruel, degrading, and inhumanetreatment. The nurse shall not voluntarily participate in any deliberate infliction of physical or mental suffering.8 (See Working Against Torture: TheImportance of Education, page 60.)Why people torture. While the media usuallyportray torture being used to extract informationfrom someone, this is just one aspect; in fact, information so obtained is notoriously unreliablebecause most people subjected to torture will admit56

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to anything. The primary goal of torturers is to gain

power over others and to silence opposition.Individuals, communities, and even entire countrieshave been controlled through the use of torture. Forexample, from 1973 to 1990 Chile was governedby a military regime led by Augusto Pinochet,on whose orders thousands of people were put todeath, tortured, or kidnapped (the disappeared)for supporting the previous regime and for protesting the Pinochet governments human rights abuses.The fear engendered silenced countless people.Considered by experts to be at epidemic levelsworldwide, torture has been used for as long ashumans have sought power over one another. AsConroy noted, Torture was routine in ancientGreece and Rome, and although methods havechanged in the intervening centuries, the goals of thetorturerto punish, to force an individual tochange his beliefs or loyalties, to intimidate a communityhave not changed at all.9The rise of the use of torture worldwide in recentyears appears related to greater political instability,economic inequality, and war, which have displacedhuge numbers of people, many of whom becomerefugees. In 1980 the U.S. Congress passed theRefugee Act, adopting the international definitionof refugee, as put forth in the United NationsConvention and Protocol Relating to the Status ofRefugees: a person who, because of well-foundedfear of being persecuted for reasons of race, religion,nationality, membership of a particular socialgroup, or political opinion, has left his home country and is unable or unwilling to return.10 Today thefederal Office of Refugee Resettlement recognizesthat many members of groups residing in theUnited States, including refugees, asylees, immigrants, other displaced persons, and U.S. citizens,may have experienced torture.11TORTURE AND ITS EFFECT ON SURVIVORSThere has been some debate among mental healthprofessionals as to whether a distinct torture syndrome exists. Regardless, its possible to identifysurvivors of torture.The physical effects of torture depend on themethods used and may involve structural damage,disturbed function, or both.12 Because victims areoften subjected to many forms of tortureseverebeatings to the soles of the feet (falanga) or otherparts of the body, prolonged immobilization, electric shock, and rapeestablishing etiology for aparticular injury is difficult. Its rare for U.S. clinicians to see refugees with recently acquired physicalinjuries because travel takes time. Chronic sequelaesuch as untreated fractures, mutilation of genitalia,or paraplegia may be present. Over the long term,survivors of torture are at increased risk for infectious disease, malignancies, cerebrovascular accihttp://www.nursingcenter.com

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Image courtesy of the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark

dents, and heart disease, as compared with nontortured, culturally matched controls, according toGoldman and Goldston (as cited by Basoglu andcolleagues in The Mental Health Consequences ofTorture).12 The reasons for the differences in risk areunknown. Survivors may also have illnesses such astuberculosis or parasitic infection acquired inprison, in a refugee camp, or by fleeing.Psychological effects. At the CVT, survivors saythat psychological torture is harder to endure thanphysical torture and that its effects are more difficultto live with. Forms of psychological torture includeprolonged interrogation, sensory deprivation, mockexecution, and being forced to watch loved onesbeing tortured.Posttraumatic stress disorder (PTSD) anddepression are the most common psychological disorders in people whove survived torture. Symptoms of PTSD commonly seen in this populationinclude reexperiencing phenomena (such as flashbacks, intrusive thoughts, and nightmares), theavoidance of stimuli associated with being tortured(such as other people from ones cultural group,people in uniforms, windowless rooms), and physiologic symptoms of increased arousal and reactivityof the sympathetic nervous system (such as hypertension, sleep disturbances, and a heightened startleresponse).12, 13 Survivors may find themselves caughtin a cycle of trying to move on with their lives asvivid reminders of the past encroach. Though it mayseem paradoxical, severely depressed survivors canhave physiologic symptoms of increased arousaland reactivity; clinicians should look for symptomsof both depression and PTSD. Other possible symptoms include social isolation, impaired memory andconcentration (which may or may not be a result ofhead injury), fatigue, sexual dysfunction (especiallyif sexual trauma has occurred), and personalitychanges.12 (See PTSD in the World War II CombatVeteran, November 2003.)Although PTSD appears to be a common responseto severe stress, the interpretation and expression ofsymptoms differs among cultural groups.14 For example, a 49-year-old Cambodian woman who survivedthe killing fields of the Khmer Rouge and emigrated to the United States several years ago reportedthat for more than 25 years she has experiencedchronic headaches, abdominal pain, nightmares, anddifficulty sleeping. Her U.S. providers attributed thesesymptoms to the extreme trauma she had endured,which included being starved, beaten, raped, andforced to witness the torture and execution of familymembers and friends. But the woman believed thather symptoms were caused by the spirit of her deadmother, who shook her feet at night because herdaughter hadnt buried her properly. Some survivorsview their suffering as punishment for bad behaviorin this or a previous life.

Surrounded by Torturers He Cannot See, Anonymous, watercolor

on paper, 8.27 11.69, early 1980s.

Somatization refers to the physical expression of

psychological needs. Most cultures regard mentalhealth in absolute termsone is either sane orcrazyand thus physical symptoms are moresocially acceptable than psychological ones. Forexample, one person might express emotional painas a gastrointestinal disorder; another might saythat his head is too hot. Survivors frequentlycomplain of head, shoulder, back, or abdominalpain, yet in many cases no physical cause can befound on examination.15 With time, as the emotional issues are addressed, the physical pain diminishes or disappears.Variations in symptoms can be tremendousamong survivors. In our experience, risk factors fora greater severity of symptoms include longer duration and greater intensity of torture, a history ofabuse during childhood (before the torture), anabsence of social support after the torture, youngage at the time of torture (children are particularlyvulnerable), and any history of mental illness.AJN October 2004

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Another risk factor is having family members who

were tortured or killed in retribution for the survivors political activities. However, as Basoglu andAker note, some torture survivors never developpsychological problems . . . others recover from thetrauma spontaneously.16 Many survivors would

Hearing the behaviors that

have allowed us to survivedescribed as deviant orpathological only reinforcesour sense that we aremisunderstood [and] alone.agree with Dianna Ortiz, an American nun whowas tortured in Guatemala, who writes, Considerably more attention must be given to our resilienceand less to what others may consider to be ourweakness, our pathological behavior.17Ortiz also notes that survivors often try to copewith the aftermath of [their] trauma by searchingfor ways to numb the pain,17 such as through alcohol or drug abuse, high-risk sexual behavior, excessive sleeping, and even self-injury or suicidalthoughts. Its important for clinicians to realize thatthough injurious in the long run, these behaviorsmay have short-term survival value for torture survivors. Ortiz cautions, Hearing the behaviors thathave allowed us to survive described as deviant orpathological only reinforces our sense that we aremisunderstood [and] alone.17 The rate of suicideamong torture survivors is unknown.According to Amnesty International (as cited byBasoglu in the Journal of the American MedicalAssociation18), torture occurs more often in the context of other severe stressors such as war and otherforms of armed conflict. Symptoms are more pronounced in refugees than in those who remain intheir homelands, because of the added stress associated with the loss of ones family, community, andcountry and having to adapt to a new culture.The families and communities surrounding survivors of torture are also profoundly affected. Astudy of 85 children whose parents had been tortured showed that 68% had emotional disorders,physical symptoms, or both.19 Specifically, 34 children had insomnia and nightmares, 34 sufferedfrom anxiety, 12 had chronic stomachaches, 13 hadfrequent headaches, 15 wet their beds, 13 had58

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anorexia, four had impaired memories, and 16

demonstrated unspecified behavioral difficulties.Conroy reports that studies of Nazi Holocaustsurvivors have found that their children and evengrandchildren have higher rates of clinical depression and suicide than the population at large.20Some of the current social problems within theAfrican-American and Native-American communities (for example, these groups have higher rates ofdomestic violence, alcoholism, and drug abuse thanmost other groups) may be the result of intergenerational transmission of the effects of torture. Withintergenerational transmission, symptoms such asdepression and low self-esteem are often seen notonly in the survivors but also in their descendantsfor generations. Maria Yellow Horse Brave Heart,associate professor of social work at the Universityof Denver, in Colorado, has labeled this phenomenon historical trauma.21 According to BraveHeart, symptoms in a community affected by historical trauma include elevated rates of suicide,depression, self-destructive behavior, substanceabuse, obsessive thoughts about past trauma, somatization, anxiety, guilt, and chronic grief. Many ofthe symptoms of historical trauma are the same asthose seen in survivors of torture.TREATMENTThe treatment of torture survivors is a relativelynew field, and much is still unknown. Althoughsome psychologists and psychiatrists had workedwith Holocaust survivors, it wasnt until the 1970sthat torture treatment began to be viewed as anarea deserving of focus. The worlds first torturetreatment center, the Rehabilitation and ResearchCentre for Torture Victims, opened in 1982 inCopenhagen, Denmark. In 1985 the CVT becamethe first such center in the United States. Currently,there are 30 centers in the United States, with moreplanned or in development, and more than 200worldwide.There is no published nursing research on torture survivors; what little research exists has beendone in the fields of medicine and psychology.There is little information on the treatment of torture survivors and thus little consensus on whichinterventions are best.13 Many survivors of tortureare unaware that their current symptoms are theresult of having been tortured.In Europe and the United States, the primarytreatment modality has been psychotherapy usingcognitivebehavioral and insight-oriented approaches.22 Cognitivebehavioral therapy emphasizes the role of thinking in how patients feel andact. The underlying premise is that thoughts, notexternal situations, cause feelings and behaviors;thus, learning to think differently will result indesired change. Insight-oriented therapies (talkhttp://www.nursingcenter.com

therapies) focus on a patients current or past experiences, thoughts, and feelings. The underlyingassumption is that gaining insight into ones feelingsand actions can bring about desired change.Psychotropic medications, especially selectiveserotonin reuptake inhibitors that have beenapproved by the Food and Drug Administration forthe treatment of PTSD, such as paroxetine (Paxil)and sertraline (Zoloft), are also used frequently inthe treatment of torture survivors. Although noresearch on their use in treating torture survivorshas yet been done, the efficacy of these drugs intreating anxiety and depression associated withPTSD is well established.Many survivors now living in the United Stateshave difficulty obtaining access to health care that isaffordable and culturally appropriate. In our experience, cultural differences in beliefs about health,illness, and care create the most formidable barriersto their getting that care. Western-based psychological treatment isnt acceptable to all survivors, andas Ortiz has noted, Talk therapy is not the onlyform of treatment that has proved useful.17 Shepoints out that treatment by traditional or folkhealers and interventions considered alternative orcomplementary in Western health care, such asherbal remedies, massage therapy, aromatherapy,and breathing and relaxation exercises, may also bevaluable. For example, a British nurse and Reikipractitioner reported that Reiki treatments helpedreduce the frequency and severity of nightmares,abdominal pain, headaches, and stress in twoBosnian torture survivors.23NURSING CARE FOR TORTURE SURVIVORSTorture assessment. If a nurse suspects that a patientmay have been tortured, an assessment for thisshould be done. A good opening question is Canyou tell me a little about what happened in yourcountry that made you come to the United States?Based on the patients response and apparent comfort level, the nurse might follow with more specificquestions, such as I know that in your countrymany people have been beaten or arrested by soldiers or rebels. Have you ever been attacked likethat? We find that its best to avoid the word torture as the word encompasses different things indifferent cultures. For example, not all cultures consider rape to be a form of torture.We have found that it can be very therapeutic forsurvivors to tell their stories. As nurses, we are oftenso busy with more concrete tasks that we sometimesforget the tremendous healing power of presenceand empathy. Indeed, in the July 1 issue of the NewEngland Journal of Medicine, Mollica noted thatdespite routine exposure to the suffering of victimsof human brutality, health care professionals tend toshy away from confronting this reality . . . theyajn@lww.com

The Center for Victims

of TortureThe first in this country.

he Center for Victims of Torture, founded in

Minneapolis in 1985, was the first treatmentcenter for torture survivors in the United States. Anindependent nonprofit organization, it offers freetreatment services to survivors living in theMinneapolisSt. Paul area, as well as in Guineaand Sierra Leone, West Africa. In Minnesota survivors work with a team of care providers, includingdoctors, nurses, psychologists, social workers, massage therapists, and physical therapists. TheMinneapolis and St. Paul treatment programs serveapproximately 200 to 300 people a year. In addition, the center provides education in working effectively with survivors of torture and war trauma forhealth care providers, students, educators, andsocial workers, training about 5,000 professionalsannually. Basic and advanced nursing curriculahave been developed, and the centers nurse trainermakes educational presentations in health carefacilities, public health agencies, and nursingschools statewide. In West Africa similar programsoffer refugees group therapy and education on theeffects of war trauma. They provide education forAfrican health care providers in how to care for survivors effectively; in some cases they also trainrefugees, who then serve as paraprofessional caregivers. In Guinea, for example, some Liberianrefugees given training in the areas of communication, counseling, and conflict resolution have goneon to work with other refugees.

believe they wont have the tools or the time to help

torture survivors once theyve elicited their history.24 Clinicians may also fear that asking the survivor to retell his story will retraumatize him.However, survivors frequently tell us that althoughtelling their stories is difficult, having someonebelieve them and show concern for them outweighsthe difficulty.Its important to let the survivor proceed at hisown pace and to tell as much or as little of his storyas hes comfortable with. Many survivors have saidthat simply being listened to is beneficial; some havenever told friends or family members what happened to them. Some survivors may be very reluctant to relate their experiences; others may tell astory without any apparent emotion. (The suppression of emotion is one sign of PTSD and can be areaction to torture.) Assurances of confidentialityare essential, as survivors often feel great shameAJN October 2004

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Working Against Torture: The Importance of Education

INTERNATIONAL DECLARATIONS

TEACHING NURSES: THE DANISH PERSPECTIVE

The United Nations. As of June 2004, 136 states

(out of 194 possible) had ratified the UnitedNations Convention against Torture and OtherCruel, Inhuman, or Degrading Treatment orPunishment (1984); the United States ratified it inOctober 1994. (For the complete text, seewww.unhchr.ch/html/menu3/b/h_cat39.htm).These states stand committed to condemning tortureand refraining from its use under any circumstances.(Ratifying the convention has not eliminated the useof torture by these states, as recent news of the torture of Iraqi prisoners by American and Britishtroops at Abu Ghraib prison indicates.)Although the convention is not directly aimed atnurses and doctors, much of it is relevant to healthcare professionals. Two articles are of particularimportance. Article 2 emphasizes that torture is neverpermissible or acceptable; it states that no exceptional circumstances whatsoever, whether a state ofwar or a threat of war, internal political instability orany other public emergency can justify the use oftorture; neither can an order from a superior officeror other authority. Article 10 makes education andinformation regarding the prohibition against torturemandatory components in the training of medicalpersonnel, including nurses.The International Council of Nurses (ICN) adoptedits first position statement against torture in 1989.Revised in 1998, its now known as the ICNsPosition Statement on Torture, Death Penalty, andParticipation by Nurses in Executions. (For the complete text, see www.icn.ch/pstorture.htm.) Thestatement reads, in part:

The Rehabilitation and Research Centre for Torture

Victims in Copenhagen (RCT), the first center of its kindworldwide, was founded in 1982. In keeping with theimportance placed on education by the aforementionedUN convention (Denmark ratified it in 1987) and theICN position statement, one of the RCTs long-standinggoals has been to offer targeted training about tortureand torture survivors to nurse teachers at Danishschools of nursing. Ultimately the goal is to make suchtraining compulsory in nursing education programs.In the autumn of 1992 the RCT planned its firstseminar for nurse teachers. The goal was to providethem with basic knowledge of torture, including thevarious methods and effects of torture, as well asrehabilitation, treatment, and services that they couldthen pass on to their students. Instruction also focusedon nurses responsibilities as outlined in the ICN position statement. The long-term objective was to teachstudents and nurses how to identify likely torture survivors and to plan care and treatment programs thatwould meet their specific needs.The RCT has continued to offer the two-day seminars every other year since 1992. As of this writing,136 nurse teachers have participated, and 35 areteaching these subjects to nursing students at severalof Denmarks 22 nursing schools. The nursing schoolscover the RCT staffs travel expenses and teachingfees; the RCT covers venue and food costs.Nurse teachers who have taken the RCT seminarhave expressed a need to share subsequent teachingexperiences with colleagues at other nursing schoolsand to continue learning about torture and the treatment of torture survivors. Theyve also sought furtherdiscussion of practical matters, such as when duringa nursing students overall course of study the subjectof torture should be taught and what course materialsshould be used. To meet these goals, the RCT nowoffers a follow-up seminar every two years. For moreabout the RCT and its work, go to www.rct.dk/usr/rct/webuk.nsf/fWEB?ReadForm&Load=RTIG-4L5JTU.Nurse teachers are enthusiastic about passing onwhat they learn about caring for torture survivors,not only to nursing students, but to RNs and otherhealth care students and professionals. They havebecome a new and vocal group in opposing the useof torture.Lone Jacobsen, MA Health, RN (specialist in management, teaching, and systemic therapy),chief nurse and psychotherapist, Rehabilitation andResearch Centre for Torture Victims, Copenhagen,Denmark, and member, ICNs Data Bank of Expertsin Ethics

The nurses primary responsibility is to

those people who require nursing care.Nurses have the duty to provide the highestpossible level of care to victims of cruel,degrading, and inhumane treatment. Thenurse shall not voluntarily participate in anydeliberate infliction of physical or mentalsuffering.The ICN also advocates the inclusion at all levels ofnursing curricula the recognition of human rights issuesand violations, including the use of torture.Nurses will meet torture survivors among theirpatients. Survivors are often very reluctant to talkabout or even mention what they have experienced,but the effects of torture will be evident if the nurseknows what to look for.60

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about the torture they experienced and may fear

what others will think. This may be especially trueif an interpreter must be present. Thus, under no circumstances should a family member or friend beused to interpret when asking a patient whether shehas been tortured.Nurses should be aware that survivors who telltheir story will need continuing care once thetrauma is revealed. Survivors trust in other humanbeings has been deliberately damaged. Nurses willneed patience and commitment in forming therapeutic relationships with torture survivors. Supporting their autonomy and allowing them as muchcontrol as possible in a given situation will help. Forexample, questions such as Where would you liketo sit? and statements such as Tell me when youdlike to take a break can be useful.25Beyond the assessment. Assisting survivors withwhatever they feel is most important at thatmoment may be the best way to support them.Often social service and economic issues are paramount, especially for recent immigrants. Survivorsmay need help obtaining basic necessities such asfood, clothing, and housing before they can begin todeal with the effects of torture. Teaching them relevant survival skillssuch as how to access and navigate the health care system or how to use masstransit, enroll a child in school, or use a bankalsohelps them gain some control of their situation andrebuilds confidence.Survivors generally need help in understandingthe link between the torture and its physical andpsychological effects. There is some controversyabout whether a survivor of extreme trauma whohas PTSD or depression can be considered to have amental illness; its argued that these are normalresponses to horrific experiences. Regardless, itseems clear that clinicians must be sensitive to whatsurvivors have endured. Ortiz, speaking on behalfof survivors, writes, We readily acknowledgethat the trauma we have endured has altered ourlives. . . . We want to be recognized as normal people, people who were tortured and who havesurvived with tenacity, grace, and dignity.17 GarciaPeltoniemi and Jaranson (as reported by Laurencein Issues in Mental Health Nursing) found thatmany survivors are tremendously relieved to hearthat symptoms they are experiencing are a directresult [of] the extreme experiences they were forcedto endure and not because they are crazy, possessedby spirits, or weak in character.26 Survivors alsowant to know which symptoms of torture are permanent and which they can expect will heal withtreatment.Routine procedures can be extremely stressful forsurvivors of torture. For example, an electrocardiogram for a survivor of electrical torture or a gynecologic exam for a rape survivor may trigger aajn@lww.com

Common Methods of Torture

Beatings with hands or objects (such as rifle butts orclubs) Electric shocks to sensitive body parts Hanging by the arms, legs, or shoulders Sexual humiliation and rape Burning with cigarettes, hot water, or acid Exposure to environmental extremes (such as veryhigh or low temperature) Being forced to stand for extended periods of time Being forced to stare at the sun Having ones head submerged in water or excrement Mock execution (for example, having an empty gunfired at ones head) Threats of violence to loved ones Being forced to watch or participate in the tortureor death of others, including loved ones Forced nakedness Not being allowed the use of a toilet Solitary confinement or overcrowding Exposure to continuous noise Sleep deprivation Being forced to remain with dead bodies Repeated interrogations conducted at random andunpredictable timesHoltan N, et al. Minn Med 2002;85(5):35-9. Adapted with permission.

flashback. Its important to prevent or minimize

such stressors to the extent possible. Many survivors can get through tests and procedures withoutbeing severely retraumatized if theyre told whatthe test or procedure will entail and are given emotional support. Sensitivity to specifics is alwaysimportant. For example, a female rape survivormight prefer a female clinician; a survivor who wastortured by someone from his own cultural groupmight be more comfortable with clinicians from adifferent background. In some cases, certain procedures (such as rectal or pelvic examinations forrape survivors) may best be done under anesthesia.Relaxation, meditation, and other coping strategiessuch as listening to quiet music also can be useful.These techniques allow survivors to calm themselves when they begin to feel anxiety.Many refugees come from cultures in which thefoods they consumed were much more nutritiousthan American fast foods; many refugees may havewalked miles daily in their home countries and findthat they get less exercise here. As would anyrefugee, survivors of torture will benefit from athorough evaluation of their diet and exercise regimen. (For more information, see From Sudan toOmaha, In Our Community, July.)AJN October 2004

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Giving LightA book of short stories offers hope of redemption.

n her 2004 book The Dew Breaker, a collection of

related stories, Edwidge Danticat looks at the life ofa choukt laroze, a man who tortured others duringHaitis Duvalier dictatorships. The term dew breaker isDanticats own translation of the Creole phrase andcould easily have been the dew shaker or the dewstomper, a reference to the way thetorturers would often abduct theirvictims at first light, disrupting themorning dew. The book presents thedew breaker through the eyes ofthose around himwife, daughter,and former victims.Set primarily in the United States,the stories offer insight into how thosewho have suffered torture survive andthe form that survival takes. The characters in Danticats book managetheir pasts with greater and lesserdegrees of success: for some, thethreat of encountering a former torturer is very real; he isthe barber in the shop on your street. For others, he existsonly in the imagination, the result of chasing fragments ofthemselves long lost to others. There is a palpable sensethat the torture has not endedin one story, the dewbreakers wife (who had also suffered loss at his hands),having just arrived in America, listens to the radio andhears callers talking about a Haitian American mannamed Patrick Dorsimond who had been killed. He hadbeen shot by a police officer in a place calledManhattan. One has the sense that the place names havechanged, but the dangers remain.In a book that swings between regret and forgiveness, Danticat gives hope. In an e-mail interview, shestated that she believes silence is a very big part of suffering and sometimes an obstacle to healing. In the storyNight Talkers Danticat writes of palannit, night talkers,those who spoke their nightmares out loud to themselves.With the character of Claude, a Haiti-born son of immigrants who was raised in America but sent home aftercommitting patricide, Danticat offers the hope of someredemptionfor the afflicted and the afflicters alike.Claude, a palannit, is both a victim and a perpetrator andis even luckier than he realized, for he was able to speakhis nightmares to himself as well as others, in the nighttimeas well as in the hours past dawn, when the moon hadcompletely vanished from the sky. Danticat believes tellingones story helps in healing. She noted, Sometimes just tohave people acknowledge what happened to you can bea great help. Perhaps The Dew Breaker serves as someacknowledgment for the torture survivors of Haiti, with stories that speak truths, told in the light of day.LisaMelhado, associate editor

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Community interventions. Nurses participation

in the development of community-based interventions that are culturally appropriate is vital. Nurseswill need to work with survivors and their communities to identify the most pressing issues and discern acceptable solutions. In addition to those builton a framework of Western psychology and talktherapy, community support groups could bebased on whatever survivors feel their needs warrant. For example, Survivors International (www.survivorsintl.org), a nonprofit organization based inSan Francisco, offers a Cambodian womens support group and a Bosnian womens sewing group.For continued support and treatment, most survivors will need appropriate referrals, ideally eitherto a torture treatment center or to a mental healthprovider specializing in emotional trauma. But torture treatment centers are not available in all areas;and even where a center is an option, some survivors may choosefor various reasonsnot to go.Other health care providers, such as clinic staff orpublic health nurses, may sometimes be the onlyprofessional help available. Yet untrained providersmay be hesitant to help. And although most torturetreatment centers offer fees on a sliding scale, thecost of services elsewhere may be prohibitive torefugees, who as a group tend to have low incomes.As of this writing, there is no central clearinghouseof providers who specialize in working with tortureand war trauma survivors.Nursing implications. Nurses need to conductresearch on appropriate and effective treatment forsurvivors, including complementary and alternativetherapies as well as Western-based modalities.Research is also needed on the effects of torture onthe family and community, as well as on effectiveways to combat the use of torture worldwide.Many pioneers of public health nursing, including Margaret Sanger, Lillian Wald, and LaviniaDock, viewed working for social justice and peaceas a nursing function.27 Laurence writes that aspromoters of health and well-being, nurses musttake responsibility in the prevention of human rightsabuses and in the promotion of human rights.26 Weagree. These are especially timely issues for nurses,given the recent public debate over the use of tortureby the U.S. military as a means of fighting terrorism.We find that an overwhelming majority of survivors attribute their survival to their spiritualbeliefs, yet this aspect is the least well incorporatedinto treatment. Nurses can help survivors by encouraging them to get involved with people and activitiesthat bring renewed meaning and a sense of worth totheir lives. Ortiz exemplifies this. About her workwith the Torture Abolition and Survivors SupportCoalition International (an organization shecofounded), she writes, I used to think that Godmade an error in allowing me to survivebut I nohttp://www.nursingcenter.com

longer believe that. . . . God, I believe, has united our

voices . . . [in] calling for an end to torture.28Nurses must have in-depth knowledge of transcultural issues with regard to responses to torture.Its also important for nurses to have some understanding of what life is like for most people in economically poor countries, what refugees have gonethrough in their home countries, and what adjustingto life in the United States entails. (One excellentresource is The Middle of Everywhere: The WorldsRefugees Come to Our Town, by Mary Pipher, afamily therapist in Lincoln, Nebraska, who writesperceptively about the lives of refugees, includingtorture survivors, from Bosnia, Vietnam, and SierraLeone, among others.)In keeping with the United Nations ConventionAgainst Torture, U.S. nursing schools must begin toincorporate education on caring for torture survivors into their curricula. In 2001 the AmericanAcademy of Nursing issued Policy Recommendations for Nurses Caring for Victims of Torture,which include the following (quoted verbatim)29: Fund and administer educational training andsupport for nurses who will develop nursing careplans to assist victims of torture to find hope andhealing. Include torture and treatment of its sequelae innursings research agenda. Develop linkages with current centers of treatment to add nursing expertise. Support a conference or institute on the topic oftorture and survivors of torture. Consider a . . . conference to develop a whitepaper on torture. Augment nursing educational training to addexpertise in treatment of victims of torture inpsychiatric mental health nurse practitionerprograms. Extend the Academys support of [these] recommendations to the ANA, ICN, and Sigma ThetaTau to ensure that the profession of nursing contributes to healing victims of torture.As of this writing, these recommendations hadnot been acted on.The impact on nurses. The prospect of workingwith survivors of torture can raise several concerns.First, nurses may fear that theyll inadvertently dosomething that exacerbates a survivors suffering.Its true that survivors are vulnerable; their vulnerability stems from a susceptibility to having traumasymptoms triggered by everyday events and, likeother refugees, to a general lack of knowledge aboutU.S. culture. But most torture survivors are alsostrong and resilient people.Its also true that many nurses dont have specialized knowledge or skills for helping people whohave been tortured. Years ago nurses were in a similar situation with regard to suspected cases of domesajn@lww.com

tic violence. Nurses often didnt ask whether

domestic violence was occurring, either because theydidnt know how to respond if it was or because theyassumed the matter was someone elses responsibility;far too often, therefore, domestic violence wasignored. Nurses need to learn to work with survivorsof torture and extreme trauma. Information on caring for survivors must be included in nursing schoolsand through continuing education courses.For caregivers, hearing about the deliberateinfliction of severe pain and suffering may be especially troubling. Nurses may worry that they toowill begin to feel hopelessness and despair.Secondary trauma is prevalent throughout nursing,yet nurses arent taught much about how to preventor address it. Caring for oneself is more than simplyfinding time to relax; it requires having a deliberateplan for balancing all aspects of ones life. Eachnurse must determine what this means for her. (Formore on this subject, see Understanding SecondaryTraumatic Stress, July 2001.) Complete the CE test for this article byusing the mail-in form available in thisissue or visit NursingCenter.comsCE Connection to take the test and findother CE activities and My CE Planner.REFERENCES1. Torture and torture victims. Fed Regist 2000;65(32):14,595-603.2. Amnesty International. Annual report [introduction]. 2004.http://www.amnestyusa.org/annualreport/index.html.3. Eisenman DP, et al. Survivors of torture in a general medicalsetting: how often have patients been tortured, and howoften is it missed? West J Med 2000;172(5):301-4.4. Jaranson JM, et al. Somali and Oromo refugees: correlatesof torture and trauma history. Am J Public Health2004;94(4):591-8.5. Jacobsen L. Teaching health professionals about torture. IntNurs Rev 1998;45(3):79-80.6. Human Rights Watch. Summary of international and U.S.law prohibiting torture and other ill-treatment of personsin custody. 2004. http://hrw.org/english/docs/2004/05/24/usint8614_txt.htm.7. World Medical Association. Declaration of Tokyo. 1975.http://www.wma.net/e/policy/c18.htm.8. International Council of Nurses. Torture, death penalty, andparticipation by nurses in executions. 1998. http://www.icn.ch/pstorture.htm.9. Conroy J. History and method. In: Unspeakable acts, ordinary people. The dynamics of torture. New York: Alfred A.Knopf; 2000. p. 27-38.10. United Nations High Commissioner for Refugees. Conventionand protocol relating to the status of refugees. 1996.http://www.unhcr.ch/cgi-bin/texis/vtx/home/+IwwBmeJAIS_wwww3wwwwwwwhFqA72ZR0gRfZNtFqrpGdBnqBAFqA72ZR0gRfZNcFq9gdDVnDBodDawDmapGdBdqdcaGncwBoDtaBdaBrna5BwB15adhaGnh1tnn5Dzmxwwwwwww/opendoc.pdf.11. U.S. Office of Refugee Resettlement. Office of RefugeeResettlement (ORR) torture treatment program. 2002.http://www.acf.dhhs.gov/programs/orr/programs/torturep.htm.12. Basoglu M, et al. Torture and mental health. A researchoverview. In: Gerrity E, et al., editors. The mental healthconsequences of torture. New York City: Kluwer Academic;2001. p. 35-62.

GENERAL PURPOSE: To provide registered professional

nurses with information on the care of torture survivors.LEARNING OBJECTIVES: After reading this article andtaking the test on the next page, you will be able to outline background information on the prevalenceand effects of torture. discuss the care of patients who have survivedtorture.

To earn continuing education (CE) credit, follow these

instructions:1. After reading this article, darken the appropriate boxes(numbers 115) on the answer card between pages 64and 65 (or a photocopy). Each question has only onecorrect answer.2. Complete the registration information (Box A) and helpus evaluate this offering (Box C).*3. Send the card with your registration fee to: ContinuingEducation Department, Lippincott Williams & Wilkins, 333Seventh Avenue, 19th Floor, New York, NY 10001.4. Your registration fee for this offering is $13.95. If you taketwo or more tests in any nursing journal published byLippincott Williams & Wilkins and send in your answers toall tests together, you may deduct $0.75 from the price ofeach test.Within six weeks after Lippincott Williams & Wilkinsreceives your answer card, youll be notified of your testresults. A passing score for this test is 11 correct answers(73%). If you pass, Lippincott Williams & Wilkins willsend you a CE certificate indicating the number ofcontact hours youve earned. If you fail, LippincottWilliams & Wilkins gives you the option of taking thetest again at no additional cost. All answer cards for thistest on The Fear Is Still in Me: Caring for Survivors ofTorture must be received by October 31, 2006.This continuing education activity for 2 contact hoursis provided by Lippincott Williams & Wilkins, which isaccredited as a provider of continuing nursing education (CNE) by the American Nurses CredentialingCenters Commission on Accreditation and by theAmerican Association of Critical-Care Nurses (AACN00012278, category A). This activity is also providerapproved by the California Board of RegisteredNursing, provider number CEP11749 for 2 contacthours. Lippincott Williams & Wilkins is also anapproved provider of CNE in Alabama, Florida, andIowa, and holds the following provider numbers: AL#ABNP0114, FL #FBN2454, IA #75. All of its homestudy activities are classified for Texas nursing continuing education requirements as Type 1.*In accordance with Iowa Board of Nursing administrativerules governing grievances, a copy of your evaluation of thisCNE offering may be submitted to the Iowa Board of Nursing.